MARS and Prometheus in Acute-on-Chronic Liver Failure: Toxin Elimination and Outcome

Extracorporeal liver support by cell-free detoxification systems, such as the molecular adsorbents recirculating system (MARS) and fractionated plasma separation and adsorption (FPSA, Prometheus), has gained widespread interest during the last decade. Both devices effectively eliminate bilirubin, bile acids, and other albumin-bound substances accumulating in liver failure. However, it is less clear whether these systems exert a beneficial effect on factors believed to be important in the pathogenesis of liver failure such as proinflammatory cytokines or parameters of oxidative stress. While initial small studies on MARS in advanced liver failure indicated improved survival, preliminary data of two recent randomized trials of either MARS or Prometheus versus standard medical treatment demonstrated no survival benefit in large cohorts of patients with acute-on-chronic liver failure.